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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800977
Report Date: 10/11/2022
Date Signed: 10/11/2022 10:31:56 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20220922142621
FACILITY NAME:WINDCHIME OF MARINFACILITY NUMBER:
216800977
ADMINISTRATOR:KARI OXFORDFACILITY TYPE:
740
ADDRESS:1111 SIR FRANCIS DRAKE RDTELEPHONE:
(415) 482-4100
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY:55CENSUS: 31DATE:
10/11/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kari Oxford - Administrator TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained unexplained injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator Kari Oxford.

It was alleged resident sustained unexplained injury while in care, more so resident was observed with large bruising on left side of torso. Reporting party indicated that when R1 was questioned, expressed that they were unsure of how the bruising occurred, were not in pain, and felt safe at the facility. LPA conducted interviews with facility staff and outside parties, made observations, and reviewed records. Documents obtained from facility revealed facility had self-reported observation of R1’s bruising, incident report received by CCL on 9/20/22 and PCP was notified. Facility reported R1 had not sustained any falls or reported any pain. Although it was reported by facility R1 is taking a medication that may cause bruising as well facility informed LPA R1 has a history of being susceptible to bruising. In addition, facility reported the bruising may have been sustained from the arms of a dining room chair R1 uses.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20220922142621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDCHIME OF MARIN
FACILITY NUMBER: 216800977
VISIT DATE: 10/11/2022
NARRATIVE
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Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are Unsubstantiated.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2